Session Objectives

ƒ Define postpartum contraception

ƒ Explain the benefits of birth-spacing
Postpartum Contraception: ƒ For both breastfeeding and non-
Family Planning Methods and breastfeeding women, discuss:
Birth Spacing After Childbirth ƒ Postpartum return of fertility
ƒ Timing and initiation of method types
ƒ Use of key contraception methods
ƒ Overview of WHO Medical Eligibility
Criteria for Contraceptive Use
JHPIEGO in partnership with Save the Children, Constella Futures, The Academy for Educational Development,
The American College of Nurse-Midwives and Interchurch Medical Assistance
2

Unmet Need: Fertility Preferences

Definitions
of Postpartum Women

ƒ Postpartum contraception is the initiation

ƒ According to many DHS surveys:
and use of family planning methods during the
ƒ 92-97% of women do not want another child
first year after delivery within 2 years after giving birth
ƒ Post-placental – within 10 minutes after placenta ƒ But 35% of women had their children spaced at
delivery 2 years apart or less
ƒ Immediate postpartum – within 48 hours after ƒ 40% of women who intend to use a FP method
delivery (e.g., voluntary sterilization) in the first year postpartum are not using one
ƒ Early postpartum – 48 hours up to 6 weeks
ƒ Extended postpartum – 48 hours up to one year
*Ross JA and Winfrey WL, 2001
after birth

3 4

Birth Spacing

ƒ Time interval from one child’s birth date

until the next child’s birth date
ƒ Healthy timing and spacing of pregnancy
ƒ Both infants and mothers are more likely to
survive if couples space their births 3 to 5
years apart
ƒ This means that couples should wait 2 years
after the birth of their last baby before trying
to conceive
Source: FHI 2000

5 6

1
 Contraception after Childbirth:
Birth Spacing Saves Mothers’ Lives
Basic Care and Services

ƒ Healthy timing and spacing of Basic care should include:

pregnancies has positive effects on
maternal health and newborn outcomes
ƒ Women who have their babies at 27 to 32
month intervals are
ƒ More likely to avoid anemia
ƒ More likely to avoid 3rd trimester bleeding
ƒ More likely to survive childbirth
ƒ Discussion of contraceptive needs
ƒ Considering client’s reproductive goals
ƒ Information and counseling about
methods, their effectiveness rates, and
side effects
ƒ Short- and long-term method choices

7 8

Contraception after Childbirth: Basic

Counseling
Care and Services (cont’d)
ƒ Assurance of contraceptive re-supply with
ƒ Encourage breastfeeding for all
access to follow-up care
postpartum women
ƒ Integration with other maternal-infant child care
ƒ Do not discontinue breastfeeding to begin
ƒ ANC and postpartum visits
ƒ Newborn care
use of a contraceptive method
ƒ Immunizations ƒ There are many contraceptive choices for
ƒ HIV/STI prevention breastfeeding women
ƒ To help clients assess their risk and make necessary ƒ These methods do not have negative effects on
changes in behavior and choose appropriate FP method breast milk or breastfeeding

9 10

Counseling (cont’d) Return to Fertility

Main goals of FP counseling:

ƒ To help women (and couples) decide if they want to use a
contraceptive method.
ƒ With the client’s permission, include partner
ƒ Birth spacing/limiting
ƒ If she does not want contraception, to help her choose an
appropriate method, taking into consideration whether or
not she is breastfeeding.
ƒ To prepare her to use the method effectively.
ƒ To help the woman develop a transition plan from LAM to
another method
ƒ To discuss return to fertility
Source: Pathfinder 1998.
ƒ During pregnancy, the cyclic function of
the ovaries is suspended due to presence
of placental hormones
ƒ During early postpartum:
ƒ Inhibiting effects of estrogen and progesterone
are removed
ƒ Levels of Follicle Stimulating Hormone (FSH)
and Luteinizing Hormone (LH) gradually rise
ƒ Ovarian function begins again

11 12

2
 Return to Fertility: Effect of Lactation Return to Fertility: Effect of Lactation
(cont’d)

ƒ Non-lactating women: ƒ Breastfeeding women:

ƒ Will menstruate within 12 weeks ƒ Period of infertility longer for exclusive or
ƒ On average first ovulation 45 days after nearly exclusive breastfeeding
delivery
ƒ Risk of pregnancy −On demand feeding blocks ovulation
ƒ Return to fertility not predictable
ƒ Likelihood of menses and ovulation is low
during first 6 months
ƒ Ovulation may occur prior to menses

13 14

When to Introduce Methods in

Breastfeeding Women
Breastfeeding Women
ƒ Protected for at least 6 months if using LAM LAM COC POC IUD BTL Con-
ƒ Fully or nearly fully breastfeeding doms
ƒ Less than 6 months postpartum
At delivery OK NO NO OK OK NO
ƒ Menses has not returned
ƒ Protected up to 6 weeks if not using LAM 3 weeks OK NO NO NO NO OK
ƒ At 6 weeks can use combined methods
ƒ At 6 weeks can use progestin only methods safely or TL 6 weeks OK NO OK OK** OK OK
ƒ All non-hormonal methods are safe for mother 6 months OK OK OK OK OK OK
and baby
ƒ Can use IUD >6 months NA OK OK OK OK OK

15 16

Non-Breastfeeding Women When to Start Contraception

ƒ Contraception should be started at the time ƒ Timing depends on

of or before first intercourse ƒ Breastfeeding status
ƒ Combined hormonal methods should not ƒ Method of choice
be used until after 3 weeks postpartum ƒ Reproductive goals

17 18

3
Medical Eligibility Criteria for Purpose of the Medical Eligibility
Contraceptive Use (MEC) Criteria (MEC)
ƒ Covers 17 contraceptive
methods, 120 medical ƒ To guide family planning practices based
conditions on the best available evidence
ƒ Addresses who can use
contraceptive method
ƒ To address and change misconceptions
based on medical about who can and cannot safely use
methods contraceptive methods
ƒ Gives guidance to
providers for clients with
ƒ To reduce medical policy and practice
medical problems or other barriers (i.e., not supported by evidence)
special conditions
ƒ To improve quality, access, and use of
http://www.who.int/reproductive-health/
publications/mec/mec.pdf
family planning services

19 20

What Is Answered by MEC? WHO Medical Eligibility Criteria

Classification Categories
With clinical With limited
Classification
judgment clinical judgment
Identifies which contraceptive or FP Yes
Use method in any
1
method can be safely used in the circumstances Use the method

presence of a given individual 2

Generally use: Yes
advantages outweigh risks Use the method
characteristic or medical condition
Generally do not use: No
3
risks outweigh advantages Do not use the method

No
4 Method not to be used
Do not use the method

21 22

Postpartum Contraception for Summary–

HIV-Positive Women Contraception and HIV Acquisition

Important information for HIV+ women:
ƒ Correct and consistent use of male and
female condoms can reduce risk of STI/HIV
transmission
ƒ Using another contraception in addition to
a condom (dual method use) reduces the
chance of pregnancy, this avoiding mother
to child transmission
ƒ Male condoms proven effective; female
condoms effectiveness may be similar to
male condoms
ƒ Spermicides (N-9) not effective against HIV
ƒ N-9 in WHO MEC is category 4 for HIV-positive
people
ƒ IUDs and hormonals do not increase HIV
acquisition from findings of observational
studies

23 24

4
 Integration of HIV with FP
ƒ HIV prevention should be an integral part
of FP services to help clients assess their
risk and make necessary changes in
behavior.
ƒ FP providers should encourage clients to
seek VCT to prevent HIV transmission to
partners, to improve quality of life if HIV-
positive, and to prevent HIV transmission
to future children.
25
Non-Hormonal Methods
ƒ Non-hormonal methods
ƒ LAM
ƒ Barrier methods
ƒ Periodic abstinence (fertility awareness, SDM)
ƒ Male and female sterilization
ƒ IUDs (Copper)
All non-hormonal contraceptive methods can
be used safely by breastfeeding women
27
Lactational Amenorrhea Method
(cont’d)
For women who exclusively breastfeed:
ƒ Fertility is delayed during the first 6 months postpartum
ƒ More than 98% protection from pregnancy
ƒ Effective, safe contraception suitable for most women
ƒ Non-hormonal
ƒ Non-invasive
ƒ Can be used as a transitional method until couple
decides on or meets criteria for another method
ƒ Can be used by HIV+ mothers in addition to condoms,
LAM is consistent with WHO guidelines for HIV+ women
29
Postpartum FP and HIV
ƒ HIV-positive women who are not breastfeeding need a
family planning method immediately
ƒ HIV-positive women who are breastfeeding may
practice LAM, but will need to choose another method
at 6 months when they stop breastfeeding
ƒ Counsel all women (even when status is unknown)
about the importance of postpartum FP:
ƒ Significance of safer sex and dual protection
ƒ Available contraceptive choices
ƒ Healthy timing and spacing if future pregnancy desired
ƒ Surgical contraception if no future pregnancy desired
26
What is
Lactational Amenorrhea Method (LAM)?
ƒ Exclusively or nearly exclusively breastfeeding
ƒ On demand around the clock feeding (every 2-3 hours)
ƒ No supplemental infant feeding
ƒ Menses has not returned
ƒ Less than 6 months postpartum
ƒ If any of these three factors change, FP is
needed to prevent pregnancy
ƒ Begin planning for FP method to transition at
6 months
28
Transition from LAM…
ƒ Before 6 months:
ƒ Assist the woman in planning for transition to
another FP method post LAM
ƒ At 6 months women will need to begin
another FP method:
ƒ Weaning from exclusive breastfeeding often
starts
ƒ Less suckling/less prolactin—ovulation no longer
inhibited
ƒ Menses and ovulation more likely
30
5
 Advantages of LAM Disadvantages of LAM

ƒ Breastfeeding practices required by LAM

have other health benefits for mother
and baby
ƒ Bonding, protects baby from diseases, healthiest
food for baby, etc.
ƒ Universally available
ƒ Can be used immediately after childbirth
ƒ No supplies or procedures needed
ƒ Bridge to other contraceptives
ƒ No hormonal side effects
ƒ No protection against STIs
ƒ Effectiveness after 6 months uncertain
ƒ Exclusive breastfeeding may not be
convenient for some women
ƒ Small chance of MTCT during
breastfeeding if mother is HIV-positive

31 32

Barrier Methods: Condoms Advantages of Condoms

ƒ Prevent STIs, including HIV/AIDS as well as

ƒ When used consistently and correctly,
male condoms are highly effective against
pregnancy and STIs/HIV
ƒ A latex sheath or covering made to fit over
erect penis
ƒ 97% effective in preventing pregnancy
when used correctly every time
pregnancy when used correctly and with each
act of intercourse
ƒ Can be used soon after childbirth
ƒ No hormonal side effects
ƒ Can be stopped anytime
ƒ No need for health provider or clinic visit
ƒ Usually easy to obtain and sold in many places
ƒ Anyone can use if not allergic to latex

33 34

Disadvantages of Condoms Fertility Awareness Methods

ƒ A man’s cooperation is needed

ƒ Based on awareness of or ability to
ƒ May decrease sensation
determine fertile time of menstrual cycle
ƒ Poor reputation—associated with immoral
sex, extra-marital sex or prostitution ƒ Includes:
ƒ May be embarrassing/uncomfortable to ƒ Basal body temperature/cervical secretions
purchase or ask partner to use ƒ Calendar calculations
ƒ Standard Days Method
ƒ Can be weakened if stored too long, in too
− Cycle beads
much heat or humidity or if used with oil-
based lubricants—may break during use ƒ Periodic abstinence during fertile period
ƒ Some men or women may be allergic to latex
35 36

6
Fertility Awareness Methods/SDM
ƒ Advantages:
ƒ Inexpensive
ƒ Not necessary to acquire supplies at
clinic/dispensary
ƒ Disadvantages:
ƒ Most methods unreliable in postpartum women
ƒ Postpartum women, especially when
breastfeeding, need to have 4 menstrual cycles,
the most recent cycle is 26 to 32 days long
ƒ Partner’s cooperation needed in periodic
abstinence
37
Male Sterilization: Vasectomy
(cont’d)
ƒ Not effective until after 3 months
ƒ Can be timed to coincide with the
postpartum period when fertility is reduced
ƒ Ideal with LAM
ƒ If not using LAM, couple will need to use another
contraceptive method during the first 12 weeks
ƒ Follow local protocols for counseling
couples in advance and obtaining informed
consent
39
Vasectomy: Safety
ƒ Very safe, with few medical restrictions
ƒ Major morbidity and mortality rare
ƒ Adverse long-term effects not been found
ƒ Minor complications (e.g., infection, bleeding,
post-operative and/or chronic pain 5-10%)
ƒ No-scalpel (NSV) technique has lower incidence
of bleeding and pain than incisional technique
ƒ Morbidity and mortality rare
41
Male Sterilization: Vasectomy
ƒ A safe, convenient, highly effective and
simple form of contraception for men that
is provided under local anesthesia in an
out-patient setting
ƒ Vasectomy is safer, simpler, less
expensive and equally effective as FS
(tubal ligation)
ƒ Vasectomy is popular in the US and UK
www.maqweb.org
Technical briefs
38
Male Sterilization: Vasectomy
(cont’d)
ƒ Highly effective in preventing pregnancy
(99.6 to 99.8% effective)
ƒ Comparable to FS, Implants, IUDs in
preventing pregnancy
ƒ Not effective immediately—WHO
recommends use of backup contraception
for 3 months after the procedure
40
Vasectomy:
Crucial Programmatic Facts
ƒ Men in every region, cultural, religious and SE
setting show interest in vasectomy, despite
common assumptions about negative male
attitudes or societal prohibitions (MAQ)
ƒ However, men often lack full access to
information and services, especially male-
centered programming, which has been shown
to result in greater uptake of vasectomy
42
7
Postpartum Female Sterilization
ƒ Ideally done within 48 hours after delivery
ƒ May be performed immediately following
delivery or during C/section
ƒ If not performed within 1 week of delivery,
delay for 4-6 weeks
ƒ Follow local protocols for counseling
clients and obtaining informed consent in
advance
ƒ Discuss during ANC
43
IUD
ƒ IUDs are among the most reliable and cost-
effective long-acting method of contraception
available to women today. IUD offers a level of
protection comparable to female sterilization with
the added advantage of easy and rapid
reversibility.
ƒ IUD prevents pregnancy by preventing
fertilization; the mechanism of action of copper
IUDs is spermicidal. Copper causes a sterile body
inflammatory reaction resulting in biochemical and
cellular changes that are toxic to sperm in the
uterine cavity rendering the sperm incapable of
fertilization.
45
Important Programmatic
Characteristics of IUDs
ƒ Effectiveness is comparable to FS
ƒ 12-13 yrs with CU-T (approved)
ƒ Cheaper to provide than other methods
ƒ Quickly and completely reversible
ƒ Very safe for most women (including:
immediately postpartum, postabortion, or
interval; breastfeeding; young; and nulliparas)
47
Female Sterilization: Effectiveness
ƒ Highly effective, 99.5% comparable to
vasectomy, implants, IUDs
ƒ Risk of failure (pregnancy), while low:
ƒ continues for years after the procedure
ƒ does not diminish with time
ƒ is higher in younger women
ƒ No medical condition absolutely restricts
a person's eligibility for FS
44
IUDs (Cu-T)
ƒ IUDs can be inserted:
ƒ Immediately after delivery of the placenta
ƒ During C/Section
ƒ Within 48 hours of childbirth
ƒ If not inserted within 48 hours, insertions should
be delayed for 4-6 weeks
ƒ Expulsion rates can be higher than with interval
insertions
ƒ Some studies show that insertion within 10 minutes of
placenta delivery is better than other times before hospital
discharge
ƒ High fundal placement has lower expulsion rates
46
IUDs: Programmatic Considerations
ƒ More service cadres can provide
(because it is non-surgical)
ƒ Choice: Long-acting methods that can be
used long-term, non-permanent. Providing
a woman with a PPIUD prior to discharge is
less than half as expensive as providing in
outpatient settings
ƒ Good option for HIV+ women
ƒ Most cost-effective method of all reversible
methods if used for 2 or more years
48
8
 Common Concerns about IUDs:
Dispelling Myths About IUDs
New Information

IUDs... ƒ Pelvic Inflammatory Disease (PID)

ƒ do not cause abortion
ƒ Infertility
ƒ do not cause infertility
ƒ are unlikely to cause ƒ HIV/AIDS
discomfort for male partner
ƒ do not travel to distant parts of the body
ƒ are not too large for small women
ƒ May offer protection against endometrial
and cervical cancer

49 50

Medical Evidence: IUD Use and HIV:

Low PID Rates and Infertility among IUD Users Three Main Questions

ƒ First 20-days: highest risk due to insertion 1. Does IUD increase risk of HIV acquisition by the
woman using it?
ƒ Beyond 20 days: PID risk is same as if no IUD „ NO
ƒ 99.8% of women with IUDs have no problems with PID
2. Does use of IUD by HIV-infected women
ƒ IUD use NOT associated with infertility increase their other health risks?
„ NO
ƒ The real culprit is Chlamydia Trachomatis (and GC),
not the IUD! 3. Does the HIV-infected IUD user increase risk to
sero-negative male partner?
„ NO

51 52

WHO Medical Eligibility Criteria:

Cu-IUD Side Effects
HIV/AIDS and Copper IUDs

3rd Ed 2004 ƒ Heavier menses in the fist few months

2nd Ed. Category
HIV/AIDS Category ƒ Increased cramping and menstrual pattern
I C
High Risk of HIV 3 2 2 changes in the first few months

HIV-infected 3 2 2
ƒ Low expulsion rate, when occurring
usually within the first 3 months
AIDS 3 3 2

Clinically well on ARV therapy 2 2

53 54

9
Summary: IUD Hormonal Methods

ƒ Comparable in safety, effectiveness to FS ƒ Progestin-only Contraceptives

ƒ Can be inserted during the postpartum ƒ Implants
period ƒ Injectables
ƒ Progestin-only pills (POPs)
ƒ Risk of PID very small , even in high STI settings
ƒ Does not increase risk of infertility ƒ Combined Estrogen-Progestin Methods
ƒ Combined oral contraceptives (COCs)
ƒ Safe for women with no children
ƒ Monthly injectables (Mesigyna, Cyclofem
ƒ Safe (and a good choice) for HIV-infected
women or women with AIDS doing well on
ARVs who do not desire pregnancy

55 56

Progestin-Only Contraceptives;
Breastfeeding Women Implants

ƒ Norplant: (will no longer be produced after 2006)

ƒ No effect on breastfeeding, breast milk ƒ 6 capsules, effective 7 years
production or infant growth and ƒ 1-yr failure rate 0.05% (1 pregnancy / 2000 users)
development
ƒ 5-yr failure rate 1.6%
ƒ WHO recommends a delay of 6 weeks after ƒ Jadelle
childbirth before starting progestin-only ƒ 2 rods, effective 5 years
methods as infants may be at risk of ƒ 1-yr failure rate 0.05%; 5-yr failure rate 1.1%
exposure to the progestin
ƒ Implanon
ƒ 1 rod, effective 3 years; with failure rate 0.07/100
♀ years (<1%)

57 58

Combined Estrogen-Progestin Methods:

Projestogen-Only Injectable Breastfeeding Women
ƒ Safe to use immediately PP if not breastfeeding
ƒ Safe to use after 6th week postpartum if breastfeeding
ƒ DO NOT use within the first 6 weeks
ƒ Injection of: postpartum
ƒ 150 mg DMPA IM every 3 mos. ƒ NOT recommended during first 6 months
ƒ 104 mg DMPA subQ every 3 months postpartum due to diminished quantity of
ƒ NET EN 200mg every 2 months breast milk, decreased duration of lactation
ƒ Women of any age and parity can use it (MEC Cat. 1,
age 18-45)
and possible adverse affects on infant
ƒ Start first 7 days after LMP, or can use any time growth
reasonably sure woman not pregnant
Source: WHO 2004
ƒ Safe to use immediately PAC

59 60

10

Combined Estrogen-Progestin Methods
ƒ BREASTFEEDING
ƒ DO NOT use combined
estrogen-progestin
methods within the first
6 weeks postpartum
ƒ NOT recommended
during the first 6 months
postpartum
Women Eligible for COCs
Without Restriction
Examples:
ƒ NON-BREASTFEEDING
ƒ NOT recommended to ƒ Adolescents
use combined estrogen- ƒ Nulliparous women
progestin methods
during the first 3 weeks ƒ Postpartum (3 weeks, if not breastfeeding)
postpartum
ƒ Safe to start after ƒ Immediately postabortion
3 weeks post-delivery ƒ Women with varicose veins
ƒ Any weight (including obese)
Source: WHO, Medical Eligibility Criteria for Contraceptive Use,
3rd Ed. 2004

61 62

Women Who Should Not Use COCs Emergency Contraception

ƒ Breastfeeding (<6 weeks postpartum) ƒ Methods of preventing pregnancy after unprotected

ƒ Smoke heavily AND are over age 35
ƒ At increased risk of cardiac valvular
disease
ƒ Have certain pre-existing conditions (e.g.,
breast cancer, liver disease, high risk of CV
disease)
ƒ Pregnant (but no proven negative effects
on fetus if taken accidentally)
sexual intercourse
ƒ Regular birth control pills used in a special higher
dosage.
ƒ ECPs are a higher dosage of the same hormones
found in daily birth control pills
ƒ within 120 hours (5 days) of unprotected sex (but as
soon as possible after unprotected sex)
ƒ IUDs can also be used 5days after unprotected sex
ƒ Distinct from RU-486 (The Abortion Pill)
ƒ Millions of unintended pregnancies and abortions
could be averted with EC

63 64

Types of ECPs ECP Effectiveness and Time

ƒ Progestin-only OCs: Levonorgestrel-only, in ƒ ECPs are effective up to 120 hours (5

preferred regimen one dose of 1.5 mg days), thought to be slightly more effective
(or can be in 2 doses of 0.75mg, 12 hrs apart)
during first 24 hours.
→88% reduction in risk (1/100 will get pregnant)
ƒ This offers providers and women more
ƒ Combined OCs: 2 doses of pills containing ethinyl flexibility of use particularly when ECPs are
estradiol (100 mcg) and levonorgestrel (0.5 mg) taken not given in advance of need.
12 hrs apart
→75% reduction in risk (2/100 will get pregnant)

65 66

11
Possible Mechanisms
Withdrawal (Coitus Interruptus)
of Action of ECPs

Depending on when used during cycle, may:
ƒ inhibit or delay
ovulation
ƒ affect sperm and ovum
function
ƒ Prevention of
implantation is an
unlikely effect
EC pills do not interrupt an established pregnancy
ƒ A traditional family planning method in which
the man completely removes his penis from
the vagina, and away from the external
genitalia of the female partner, before he
ejaculates.
ƒ CI prevents sperm from entering the woman's
vagina, thereby preventing contact between
spermatozoa and the ovum.

67 68

CI: Effectiveness CI or Withdrawal

(cont’d)

This method may be appropriate for postpartum

ƒ When used perfectly, effectiveness can be women and couples:
as high as 95% ƒ Who are highly motivated and able to use this method
effectively;
ƒ With typical usage, effectiveness about 75
ƒ With religious or other reasons for not using other
to 81% methods of contraception;
ƒ However, CI is better than no method at ƒ Who need contraception immediately and have entered
all! into a sexual act without alternative methods available;
ƒ Who need a temporary method while awaiting the start
of another method; and
ƒ Who have intercourse infrequently.

69 70

Advantages of CI Disadvantages of CI

ƒ If used correctly, does not affect ƒ Does not provide protection against STIs
breastfeeding and is always available for
primary use or use as a back-up method ƒ Requires the man’s self control
ƒ Involves no economic cost or use of ƒ May reduce the pleasure of intercourse
chemicals ƒ During withdrawal, some sperm may have
ƒ No health risks associated directly with CI already entered into the women’s vagina
ƒ Men and women who are at high risk of STI/HIV
infection should use a condom with each act of
intercourse.

71 72

12
 To save lives, parents should wait until their baby
Helpful Resources is 2 years old before they try to get pregnant again

WHO, Rivers of life

ƒ http://www.fhi.org/en/RH/Pubs/servdelivery/index.htm
ƒ http://www.who.int/reproductive-
health/publications/mec/mec.pdf
ƒ http://www.reproline.jhu.edu/
ƒ http://www.engenderhealth.org/wh/fp/index.html
ƒ http://www.maqweb.org/iudtoolkit/

73 74

13